# A nurse is caring for a client with major depressive disorder and a history of alcohol use disorder who is experiencing suicidal ideation. The client is at risk for alcohol withdrawal. Which nursing intervention should be the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543415 > language: ko > subject: Mental Health ## 문제 A nurse is caring for a client with major depressive disorder and a history of alcohol use disorder who is experiencing suicidal ideation. The client is at risk for alcohol withdrawal. Which nursing intervention should be the priority? ## 보기 1. Encourage the client to participate in group therapy sessions 2. Monitor for signs of delirium tremens and seizure activity **✔ 정답** 3. Provide nutritional supplements and encourage fluid intake 4. Administer prescribed anxiolytic medications as needed **정답: 2** ## 해설 Monitoring for delirium tremens and seizure activity is the priority to prevent life-threatening complications during alcohol withdrawal. Other interventions like group therapy, nutrition, and anxiolytics are important but secondary in the acute phase. ## 심화 해설 Understanding the Priority: Safety in Suicidal Ideation When a client with major depressive disorder (MDD) presents with suicidal ideation, the immediate priority is ensuring physical safety. In the context of psychiatric nursing, safety encompasses not only direct self-harm but also the prevention of physiological crises that can rapidly become life-threatening. While all the listed interventions may be part of a comprehensive care plan, the nurse must first identify and address the condition that poses the most acute and imminent risk to the client's life. Why Monitoring for Delirium Tremens and Seizures is the Priority The correct answer, option 2, directs the nurse to monitor for delirium tremens (DTs) and seizure activity. This intervention is prioritized because it addresses a potentially fatal physiological condition that can co-occur with or be masked by psychiatric symptoms. The rationale is rooted in the high comorbidity between MDD and substance use disorders, particularly alcohol use disorder. A client admitted with MDD and suicidal ideation may also be at risk for alcohol withdrawal syndrome (AWS), which can be fatal if unrecognized and untreated. The provided evidence underscores the critical nature of this link. One study on AWS management highlights that alcohol consumption is significantly associated with mental health disorders like depression and anxiety, and that effective management of acute AWS is essential to improving health outcomes [2]. If a client with untreated or undertreated AWS begins to experience severe withdrawal, the progression can include autonomic instability, hallucinations, and the life-threatening state of DTs, characterized by severe confusion, agitation, and grand mal seizures. A seizure itself can lead to hypoxia, aspiration, and physical injury, directly endangering the client's life. Therefore, the nurse's first clinical responsibility is to rule out or manage this acute physiological emergency, which takes precedence over psychosocial or nutritional interventions. The use of validated tools like the modified Minnesota Detoxification Scale (mMINDS) is recommended to objectively score withdrawal symptoms and guide treatment, a practice being implemented in psychiatric facilities to improve patient safety [3]. Analysis of Other Options - Option 1: Encourage the client to participate in group therapy sessions. Group therapy is a valuable therapeutic intervention for MDD, but it is not the immediate priority for a client in an acute crisis. A client actively experiencing suicidal ideation or severe physiological withdrawal lacks the cognitive stability and physical safety necessary to meaningfully participate in or benefit from a group setting. The client's physiological and immediate psychological safety must be established first, a principle central to the integrated emergency-critical care models described for psychiatric patients with severe comorbid conditions . - Option 3: Provide nutritional supplements and encourage fluid intake. Maintaining nutrition and hydration is a fundamental aspect of holistic nursing care. However, this intervention addresses a long-term or maintenance need, not an acute, life-threatening crisis. A client on the verge of DTs or a seizure is at immediate risk of death, which supersedes the need for nutritional support. Furthermore, a client with an altered level of consciousness from severe withdrawal is at high risk for aspiration with oral intake, making this intervention potentially dangerous without a prior safety assessment. - Option 4: Administer prescribed anxiolytic medications as needed. While benzodiazepines (BZDs) are the cornerstone of treatment for AWS and are used as anxiolytics, their administration is not the first step in the nursing process. The priority nursing intervention is assessment. The nurse must first monitor and assess the client’s condition to determine the need for the medication. Guidelines recommend using a validated clinical withdrawal scoring tool to assess severity before administering treatment [3]. Furthermore, the evidence cautions against the prolonged and unmonitored use of BZDs due to risks of dependence and safety concerns . The nurse’s role is to assess, recognize the signs of escalating withdrawal, and then administer the medication based on a validated protocol, not simply to give it on an as-needed basis without a structured assessment framework. The assessment of seizure risk and DTs signs is the critical first step that guides the safe administration of the prescribed medication.References (research sources) - [2]Clinical characteristics and outcomes of adult patients admitted to acute care settings for alcohol withdrawal syndrome.Research articleSalehi A, Barman M, Illahi MN, Alhariri BNA, Nashwan AJ, Singh K. (2026) · DOI: 10.5339/qmj.2026.6 - [3]Implementation of mMINDS monitoring for alcohol withdrawal at an inpatient academic psychiatric facility.Research articleSurbaugh LA, Kelsey T, Melton BL, Moeller KE. (2025) · DOI: 10.9740/mhc.2025.08.201 ## 임상 시나리오 Safety First in Psychiatric SettingsRuling Out Life-Threatening Physiological Causes When a client with major depressive disorder and suicidal ideation is admitted, the nurse's immediate priority is to identify and manage any co-occurring, potentially fatal physiological condition. Alcohol withdrawal syndrome is a common and life-threatening comorbidity that can mimic or exacerbate psychiatric symptoms. The priority intervention is to monitor for delirium tremens and seizure activity. Unrecognized and untreated, these can rapidly lead to death. A thorough assessment for autonomic instability, hallucinations, and tremors is critical within the first 24 to 72 hours of admission. Clinical AlertDo not assume that agitation, confusion, or increased depression are solely psychiatric in origin. Always screen for substance use and initiate the CIWA-Ar protocol if withdrawal is suspected. Safety and physiological stabilization always precede psychosocial interventions like group therapy. ## 핵심 개념 - **Delirium Tremens** — A severe form of alcohol withdrawal involving sudden and severe mental or nervous system changes, which can be life-threatening. - **Suicidal Ideation** — Thoughts about, or an unusual preoccupation with, suicide, ranging from fleeting thoughts to detailed planning. - **Priority Setting** — The process of ranking nursing diagnoses or client problems to determine the order of nursing interventions based on urgency and life-threatening potential. - **Alcohol Withdrawal Syndrome** — A set of symptoms that can occur when an individual reduces or stops alcohol consumption after prolonged, heavy use, ranging from anxiety to seizures and DTs. - **Comorbidity** — The simultaneous presence of two or more diseases or medical conditions in a patient, such as major depressive disorder and alcohol use disorder. ## 같은 주제 문제 - [A nurse is assessing a 28-year-old client admitted to the emergency department with suspec…](https://mymerci.kr/pages/nclex_q.php?qn_id=543409) - [A nurse is assessing a 45-year-old client admitted to the emergency department with suspec…](https://mymerci.kr/pages/nclex_q.php?qn_id=543410) - [A nurse is assessing a 35-year-old client who was admitted to the emergency department fol…](https://mymerci.kr/pages/nclex_q.php?qn_id=543411) - [A nurse is assessing a 28-year-old client admitted to the emergency department with suspec…](https://mymerci.kr/pages/nclex_q.php?qn_id=543412) - [A nurse is caring for a client with alcohol use disorder who is experiencing withdrawal sy…](https://mymerci.kr/pages/nclex_q.php?qn_id=543413) - [A nurse is assessing a client with alcohol withdrawal in the emergency department. 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